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18 Cards in this Set
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- Back
Vaginal pH, Normal levels, maintenance
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Healthy pH in premenopausal women is 3-4.5. Over 5 is abnormal, Gray zone from 4.5-5.0.
As age, pH rises At puberty, Lactobacillus acidophilus dominates flora and contributes to vaginal pH by lactic acid synthesis and hydrogen peroxide by glycogen breakdown protects against anaerobic bacteria |
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Vaginal Squames, Estradiol and pH
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Mature Vaginal Squame - large, glycogen rich, creates lower pH (3-4.5) and has higher serum estradiol. Higher risk for yeast infection but kills anarobes
Intermediate vaginal squame - estrogen decreases, lactobacilli drop, pH rises, glycogen less and cells smaller Parabasal vaginal squame - post menopausal, looks like bulls-eye. Little glycogen. pH > 5.0. LOW estrogen |
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High vaginal pH possible causes
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Bacterial vaginosis
Trichomonas vaginalis - inflammatory rxn, serum oozing into vagina, cytokines Menopause on no HRT - always have elevated pH unless obese (more estrogen) Presence of blood (blood pH is 7.4) Breastfeeding - suppresses ovarian function Topical vaginal medications Recent intercourse with semen in vagina - semen is alkaline/neutral |
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Vaginal Candidiasis Presentation, Causes, Dx, Treatment
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Presentation - Vaginal irritation and discharge, itching and burning. Sexually active, history of normal menstruation cycles
thrush-like patcheson vulva, labial edema, clitoral edema, sore, itchy bottom; don't need saline wet mount to dx Causes a) Candida albicans - most common b) Candida glabrata - second most common Others in immunosuppressed pts Dx - saline wet mount a) C. albicans - 90% - BRANCHING YEASTS, replicate via germ tube extension, CHITINOUS framework. Pseudohypae and mycelia. KOH will wash all but chitin framework b) C. glabrata - BUDDING yeasts Treatment a) C. albicans - sensitive to azoles and triazoles, tablet b) C. glabrata - resistant to azoles but sensitive to triazoles (fluconazole) FLUCONAZOLE gets both |
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Risk Factors for Recurrent/Persistent Vaginal Candidiasis
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Broad spectrum Abx - alters normal vaginal flora, yeast opportunistic infection
Pregnancy - more sugar due to high estrogen leading to higher glycogen in vagina Oral contraception - progesterone may slightly lower T cell function (1st line against fungi), right before periods may be at more risk Diabetes - high glycogen, altered immune function Immune compromise - HIV pos |
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Vulvovaginal Candidiasis Therapy Uncomplicated vs Complicated vs Pregnancy
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Uncomplicated - Fluconazole or intravaginal miconazole, clotrimazole, terconazole
Complicated/Recurrent/Persistent - Fluconazole, need culture for positive identification and sensitivity if no response. Better for uncontrolled diabetics, etc. Pregnancy - NOT OK TO TREAT WITH ORAL FLUCONAZOLE. Use topical clotrimazole, miconazole, butoconazole, terconazole |
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Vaginal Trichomoniasis Presentation, Causes, Dx, Treatment, MOA, ASE
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Presentation - Vaginal irritation with BURNING and FOUL SMELLING discharge. Dyspareunia (painful intercourse) Multiple partners, STD history. Can be asymptomatic but usually not
MOST COMMON NON-VIRAL STD in world. Vector for HIV transmission Cause: Trichomonas vaginalis - flagellated protozoa Dx - Flagellated organism on wet prep Therapy - Metronidazole first line, MOA - diffuses in and converted to free radicals to kill ASE of bitter taste, nausea, vomiting esp. with alcohol. Rarely pancreatitis, blood dyscrasias, anaphylaxis, need to treat partners Alternative Therapy - Some metronidazole resistant trichomonas, but usually pts just undertreated. If resistant though TINIDAZOLE or CLOTRIMAZOLE (intravaginal suppository) |
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Bacterial Vaginosis Presentation, Cause, Association, Diagnosis
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Presentation - RECURRENT problem, FOUL SMELLING DISCHARGE, multiple visits and dx's of bacterial vaginitis (itis means fighting, osis means not), Cyclic
Cause - High levels of anaerobic bacteria with absent lactobacilli. pH > 4.5. Often Bacteroides, prevotella, preptostreptococci, mobiluncus, gardnerella, mycoplasma Associations - no known cause or predisposition but if have likely to get: a) Poor pregnancy outcome - premature rupture of membranes, preterm labor, chorioamnionitis, postpartum endomyometritis, post cesarean wound infection b) Pelvic inflammatory disease c) Post hysterectomy vaingal cuff cellulitis Diagnosis - Vaginal pH>4.5; abnormal, malodorous discharge, amine odor on KOH addition, Presence of clue cells (squamous cells with indistinct borders due to bacterial lode) on saline wet mount. LACK of lactobacilli and leukocytes (not fighting infection) |
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Therapy, Persistence/Recurrents and Alt. Therapy for bacterial vaginosis
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Therapy - same as for trichomonas b/c treating anaerobes. METRONIDAZOLE or CLINDAMYCIN
Peristence/Recurrent BV - Recurs in 40%, no evidence that is a STI. Due to biofilm of dense slime of bacterial polysaccharides. Resistant to Abx, pH, and host defense Recurrent BV treat with longer courses of Metronidazole, consider Tinidazole Alt therapy - acidic douching, lactic acid gels, probiotics are INEFFECTIVE |
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Vulvar Diseases with Red Lesions, Treatment
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a) Contact Dermatitis - usually symmetrical eruption. Dry if chemical/perfume, wet if environmental like poison ivy. Eczematoid. Treat with corticosteroids and antihistamines for itching
b) Seborrheic Dermatitis - OILY red lesions, symmetric, RARELY ONLY IN VULVA, often on SCALP, FACE, and NASAL CREASE. cause in increased sebum. Treat with Selenium sulfide, oral contraceptives to decrease androgens (less oil) c) Coital Trauma - Honeymoon vulvitis - red, painful posterior aspect of vestibule. Just outside hymenal ring. Superficial fissuring that burns on urination. Treat with pelvic rest, topical steroid d) Tinea Cruris - Jock itch by dermatophyte, symmetric red rash, dry with scaly raised margin. Aggravated by heat and humidity. Usually tricophyton rubrum or epidermophyton fluccosum. Treat with Terbinafine (lamisil) |
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Vulvar Diseases with White Lesions, Treatment
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a) Intertrigo - hyperkeratosis of skin, waterlogged keratin that itches. Extends into thigh creases secondary to chronic wetness in obese or clothes. Treat with ZINC OXIDE for diaper rash, astringent baby wipes after urination, defecation. Steroids if itch, less occlusive clothing
b) Vitiligo - AD depigmentation of skin, whitening c) Lichen Sclerosus - Parchment-like, atrophic change. EPITHELIAL THINNING. More in peri-menopausal or menopausal. Can get labial fusion. May get vulvular pruritis. Lichen Sclerosus is NOT in vagina (never on mucous membranes) but Lichen Planus can be. Also on neck, trunk, eyelids. Treat with Clobestasol propionate (corticosteroid), then drop to betamethasone or triamcinolone (medium steroids) d) Lichen Simplex Chronicus - HYPERPLASTIC DYSTROPHY, SQUAMOUS HYPERPLASIA. Thick, inflammed hyperkeratotic skin 2ndary to INFLAMMATORY PROCESS. VELVETY SKIN. chronic pruritis. Systemic steroids e) Condyloma Acuminata - warty, cauliflower growths, can be multiple. Flesh colored. Associated with HPV 6 and II. Beware if sessile and pigmented b/c may be carcinoma in situ so biopsy. Treat with acetic acid (make sure not carcinoma), podophyllin or CO2 laser, cryotherapy |
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Ulcerous Disease Lesions of Vulva, Dx and Treat
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a) Syphilis - primary chancre is PAINLESS, Secondary syphilis ulcers have rash on palms of hands and feet. Dx with FTA-ABS or PRP/VDRL. Penicillin to treat
b) Herpes Simplex - Vesicles, usually multiple lesions, inflammation and itching. Tends to recur in same location but less severe later. Treat with Acyclovir, famcyclovir or valcyclovir c) Crohn's Disease - "Slit like" lesions involving lateral aspect of vulva extending into thigh crease, wet, oozy, secondary to CHRONIC NON-CASEATING GRANULOMATOUS PROCESS, abdominal pain and weight loss. Treat with Methotrexate, prednisone, excise lesions |
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Paget's Disease in Vulva
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Tumor that can be in vulva
Raised, velvety red lesion with islands of hyperkeratosis, locally invasive. Recurrence, 25% have underlying adenocarcinoma of apocrine glands. Widely excise and ensure no adenocarcinoma of Bartholin's glands. If adenocarcinoma then do radical vulvectomy with nodes |
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Melanoma in Vulva
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Biopsy highly pigmented, especially with ulceration and irregular borders, prone to distant metastasis, early or late
Radical vulvectomy with nodes |
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Vulvar Intraepithelial Neoplasia (VIN) in Vulva
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Diffuse plaques of white epithelium. PCR for HPV 16,18 (HIGH RISK); may be warty, sessile, hyperpigmented or not, solitary or multifocal. Biopsy before initiation of therapy. Wide excision, CO2 laster for small involvement
Can progress to squamous cell carcinoma if do not treat |
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Most common reason for pt visits to ob/gyn in US
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Vaginitis
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Wet mount with lack of WBC and lactobacilli
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characteristic of bacterial vaginosis
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How to treat vulvar condyloma that are hyperpigmented or sessile
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IF NOT carcinoma in situ or carcinoma usually can just do topical rx like TCA and podophyllin and a biopsy not necessary
High risk HPV 16,18 more likely to cause cancer |